The nurse applies a moisture-retentive dressing to a client's wound. The nurse understands that the main advantage of this dressing, rather than a wet dressing, is its ability to:

Provide autolytic debridement.

Decrease epidermal resurfacing.

Enhance the absorption of topical medications.

Promote the formation of a protective scab that traps excess exudate.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Autolytic debridement is the natural process by which the body breaks down and removes dead tissue. Moisture-retentive dressings create an optimal environment for this process, facilitating wound healing.

Choice B rationale

Decreasing epidermal resurfacing is not a recognized benefit of moisture-retentive dressings. These dressings aim to promote healing, not inhibit epidermal growth.

Choice C rationale

While moisture-retentive dressings can help with the absorption of topical medications, this is not their main advantage. The primary benefit is creating a conducive environment for autolytic debridement.

Choice D rationale

Promoting the formation of a protective scab that traps excess exudate is not the main advantage of moisture-retentive dressings. In fact, these dressings help manage exudate and reduce the risk of infection without forming a scab.

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Correct Answer is D

Explanation

Choice A rationale

Necrosis is tissue death resulting from prolonged pressure, often a consequence rather than the direct cause of pressure ulcers. The primary cause is sustained pressure impairing blood flow.

Choice B rationale

Low capillary pressure does not directly cause pressure ulcers. They result from sustained external pressure exceeding capillary perfusion pressure, leading to ischemia and tissue damage.

Choice C rationale

Increased mobility actually prevents pressure ulcers by reducing sustained pressure on any one area, enhancing blood flow and tissue health. Immobility is a significant risk factor, not increased mobility.

Choice D rationale

Extrinsic factors like sustained pressure, friction, shear, and moisture contribute directly to pressure ulcer development by compromising skin integrity and blood flow, leading to tissue ischemia and damage.

A. Rigidity. B. Flaccidity. C. Ataxia. D. Clonus.

Correct Answer is D

Explanation

Choice A rationale

Rigidity is characterized by a continuous resistance to passive movement in any direction and does not specifically occur during abrupt dorsiflexion of the foot.

Choice B rationale

Flaccidity refers to decreased muscle tone or limpness, which is the opposite of hyperactivity or spasticity, and would not be observed with abrupt dorsiflexion.

Choice C rationale

Ataxia involves uncoordinated or erratic movements and is related to cerebellar dysfunction. This is not specifically triggered by abrupt dorsiflexion of the foot.

Choice D rationale

Clonus is the correct term for rhythmic, involuntary contractions of a muscle that occur when it is suddenly stretched, such as with abrupt dorsiflexion of the foot. It is a sign of hyperactive reflexes and upper motor neuron lesions.

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The nurse applies a moisture-retentive dressing to a client's wound. The nurse understands that the main advantage of this dressing, rather than a wet dressing, is its ability to:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Pressure ulcers are caused by:

Correct Answer is D

Explanation

Which occurs when reflexes are hyperactive when the foot is abruptly dorsiflexed?

Correct Answer is D

Explanation

A nurse practitioner prescribes a therapeutic bath for a client with an exacerbation of psoriasis. The nurse tells the client to make sure the bath area is well ventilated. Which of the following is the therapeutic bath solution prescribed by the nurse?

The nurse documenting an acute open wound should include which characteristics? Select all that apply.

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The nurse assesses two new wounds located on a client's right and left buttocks. Which intervention for wound management would the nurse employ? Select all that apply.

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